1: Your Office Name

Please enter the name of your office or medical practice.

2: Your Role

What is your position in the office?

3: Primary Imaging Center

Please select the imaging center location where you primarily send patients.

4: Operations

Please rate us on the following using a scale of 1-5

1
POOR
 2
FAIR
 3
AVERAGE
 4
GOOD
 5
EXCELLENT
NOT
APPLICABLE
Ease of getting through by phone
Ease of scheduling an appointment
Friendliness of staff
Image quality
Report turnaround time
Access to images/reports online

5: Radiologists

Please rate us on the following using a scale of 1-5

1
POOR
 2
FAIR
 3
AVERAGE
 4
GOOD
 5
EXCELLENT
NOT
APPLICABLE
Accuracy / Quality of reports
Radiologist availability for consultation

6: Patient Experience Feedback

Please rate us on the following using a scale of 1-5

1
POOR
 2
FAIR
 3
AVERAGE
 4
GOOD
 5
EXCELLENT
NOT
APPLICABLE
Customer Service
Cleanliness of our imaging center
Location / Access to our imaging center

7: Overall

Please rate us on the following using a scale of 1-5

1
POOR
 2
FAIR
 3
AVERAGE
 4
GOOD
 5
EXCELLENT
NOT
APPLICABLE
How well do we anticipate your needs
Likelihood you will refer to our imaging center again
Our service favorably differentiates us from other imaging providers

8: Additional Comments

What is most memorable about our service?

What one thing could we do to enhance our service to your practice?

Other comments?

You may choose to remain anonymous or provide us with identification so we may follow-up on your specific needs.

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